Nurses' HMO bill fight goes to the Senate

Practitioners seek care provider status, pay, credit for work

`David and Goliath'

Strong doctors' lobby says measure may hurt quality of service

After three years of fierce lobbying, the General Assembly is ready today to settle a turf battle between doctors and nurses that goes to the core of who they are and what they do.

The state's 1,600 nurse practitioners, casting themselves as scrappy underdogs against Maryland's leading physicians' group, have fought for legislation allowing patients in HMOs the option of selecting practitioners as their primary care provider. Maryland's health maintenance organizations allow only doctors to assume that role.

To the nurses, the legislative battle symbolizes their attempt to step out from behind doctors' shadows.

To the doctors, it is about stature and ensuring nurses don't assume a role for which they may not be trained.

To lobbyists, it is about winning.

Joseph H. Schwartz III, a lobbyist for MedChi, the Maryland State Medical Society, smiled and puffed on a cigar when asked whether his client would win today's vote in the Senate and defeat the nurses' bill.

"It's a one-vote bill," was all Schwartz would say -- a reference to the margin by which nurse practitioners prevailed in the Senate last year, only to see the measure die in the House.

This year's version of the legislation was defeated on the House floor March 20. But the next day, supporters resurrected it and -- after a period of intensive lobbying -- got it passed on a 73-49 vote. The victory set off a gleeful celebration in which nurses and delegates cried and hugged in the State House rotunda.

Attention has shifted to the Senate for its decisive vote in the last hours of the 90-day legislative session.

"Talk about David and Goliath," said Sen. Paula C. Hollinger, a Baltimore County Democrat who is a nurse. "If this loses, there is no reason other than the force of the medical lobby. We don't have the resources the doctors have."

Nurse practitioners, known as NPs, are specially trained nurses who treat patients and write prescriptions. Most of Maryland's NPs have master's degrees.

NPs function as primary care providers in some states under Medicaid, the government health program for the poor. Federal law permits Medicare, the insurance program for the elderly, to provide reimbursement to nurse practitioners. But HMOs remain a holdout in Maryland and many other states.

"It's very much about respect," said Marilyn Edmunds of Ellicott City, program planner for the National Conference of Nurse Practitioners. "Everything we do is under the physician's name, but after 35 years we've grown to be accepted and the HMOs are the last little piece."

`A red herring'

Most NPs are female, and some opponents of the bill accuse the nurses of casting the issue as a referendum on working women.

"They've made this into a gender issue," said Schwartz, a familiar figure around the State House who also represents pharmaceutical companies, insurance agents and the solid waste industry.

"We know gender is a political subtext, but it's a red herring," Schwartz said. "It diverts attention from the real issue, which is: Should we require HMOs to give you people who are less qualified in training and clinical experience? We think people ought to go to medical school if they want to be doctors."

The bill would allow HMOs to assign nurse practitioners to fill up to half of their primary care provider slots. HMOs would be forbidden from requiring patients to see NPs, who generally charge less for their services than doctors do.

Since some HMOs base their payments to doctors on seeing a certain number of patients, some of the bill's critics believe physicians could suffer financially if NPs begin assuming a significant share of the caseload. "The purpose of this bill is for the nurse practitioners to hang out a shingle and create a flow of patients," Schwartz said.

Pay and credit

But the nurses' advocates reject the notion of a power play.

"Nurse practitioners are in no position to put physicians out of practice, nor has anyone seriously proposed that they are qualified to do so," said Del. Joan B. Pitkin, a Prince George's Democrat, in a letter to opponents of the bill.

"This bill may result in NPs getting the credit and the pay they deserve for the work they already do; they cannot do this as long as they operate as `ghost providers' behind a physicians' provider number," Pitkin said.

But Pitkin's letter also offered a subtle reminder of the power of doctors' groups, which contribute heavily to federal and state candidates' campaigns.

"I know you will be disappointed with my vote and I hope when considering your support for my candidacy in 2002, you will take into consideration all my other votes helpful to the medical profession," she said in her letter, which she said was sent to the medical society and doctors, among others.

In an interview, Pitkin said she didn't fear MedChi but acknowledged that the association has "a lot of influence" and that she wanted to explain her vote.

"I was just second-guessing how some people might take my position," she said.